Provider Demographics
NPI:1215062229
Name:LOFTIS, LYNDA MARIE (LADAC)
Entity type:Individual
Prefix:
First Name:LYNDA
Middle Name:MARIE
Last Name:LOFTIS
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:LYNDA
Other - Middle Name:MARIE
Other - Last Name:ATYEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2435 OAK PARK DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5038
Mailing Address - Country:US
Mailing Address - Phone:931-510-9775
Mailing Address - Fax:
Practice Address - Street 1:2435 OAK PARK DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506
Practice Address - Country:US
Practice Address - Phone:931-510-9775
Practice Address - Fax:615-528-9403
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1118101YP2500X, 101Y00000X, 251S00000X, 405300000X, 101YA0400X
171M00000X, 174200000X, 177F00000X, 251B00000X, 251V00000X, 251X00000X, 347E00000X
TN079962201172A00000X, 347C00000X
TN0330175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No174200000XOther Service ProvidersMeals
No175T00000XOther Service ProvidersPeer Specialist
No177F00000XOther Service ProvidersLodging
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
No251X00000XAgenciesSupports Brokerage
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376955Medicare ID - Type UnspecifiedGROUP NUMBER